Understanding PQRS and Anesthesia Billing

The Physician Quality Reporting System (PQRS) is a quality reporting system created by the Centers for Medicare & Medicaid Services designed to properly assess the quality of care that is provided to patients.

Providers can use PQRS to quantify how often they are meeting a certain quality metric, and can modify their care based on feedback provided to them by CMS (particularly in relation to their peers).

Of course, the main reason many providers want to understand and embrace PQRS is due to fee adjustments that result from not adequately participating. Failure to participate will result in a 2.0% adjustment in their fee schedule amounts in 2018 for the 2016 reporting period. That adjustment is scheduled to increase in coming years.

For anesthesia providers, there is much to understand about PQRS and anesthesia billing. Here is a breakdown of what providers need to know to familiarize themselves with the program.

Quality Measures in PQRS

The particular measures of quality contained in PQRS and anesthesia billing change from year to year. They also vary by specialty. Those for anesthesia are different from those for, say, physical therapy. The general areas on which the system focuses typically include:

Care coordination

Patient safety and engagement

Clinical processes and effectiveness

Population/public health

Providers can select the appropriate measures to use in their reports. One rule is the 2016 cross-cutting measures requirement. This stipulates that a provider must use a cross-cutting measure – one that is “broadly applicable across multiple providers and specialties” – if they have had at least one Medicare patient with a face-to-face encounter. For anesthesia professionals, most, if not all, visits will involve a face-to-face encounter.

Understanding the Value-Based Modifier

Under the Affordable Care Act, a value-based modifier is now required by CMS (as of 2015). This is an effort to move toward pay-for-performance and away from fee-for-service.

As of January 1, 2016, the value-based modifier will be applied to all physician groups under a single Taxpayer Identification Number (TIN) with 10 or more eligible professionals. In 2016, however, the modifier will not be applied if a group had at least one eligible professional participate in the Medicare Shared Savings Program, the Pioneer Accountable Care Organization Model, or the Comprehensive Primary Care Initiative.

Anesthesia providers need to prepare for 2017, when the modifier will be applied to all TIN groups that include solo practitioners or groups with two or more eligible professionals.

Value-based modifiers are selected on a tiered system known as “quality-tiering.” Quality-tiering will become a very significant factor in determining payment, and will deliver either upward, downward, or neutral fee adjustments based on your particular tier. The tiers will be evaluated based on how well a provider group performs compared to the national mean – better, the same, or worse.

Quality tiering can dramatically influence payment adjustments. For example, the highest adjustment tier in coming years will be a negative 4-percent adjustment for those found to be in the bottom third tier among their peers. The system is designed to provide an incentive for provider groups to be at least in the top 50% of all peer providers in order to avoid negative adjustments.

Categories for the Value Modifier

In 2016, as in 2015, all provider TINs will be grouped into two categories:

Category 1: TINS that met the criteria as a group to avoid the 2016 PQRS payment adjustment, or in which at least 50% of eligible professionals in the TIN met the criteria to avoid the adjustment as individuals.

Category 2: TINs subject to the 2016 Value Modifier that do not meet the criteria for inclusion in Category 1. The modifier for Category 2 will be a negative 2.0% adjustment, in addition to any negative payment adjustment under PQRS.

Adapting to PQRS and Anesthesia Billing

PQRS is a complicated subject, and can be confusing even for veteran anesthesia billing teams. The ideal situation is one in which a provider turns to a third-party specialist that has experts well-versed in PQRS and all aspects of the program – especially how they apply to a billing situation.

PQRS isn’t something that can be ignored or set aside. It will have a major impact on the financial health of a practice and should be taken seriously. An anesthesia billing provider can help comply with PQRS and all that it requires.